OSCE Neuro Examine Cranial Nerves 1-2
1. Wash hands, appropriate dress and grooming. Introduces self and asks for consent. * Hello my name is Yang Vang and I'm a first year medical student at AUA, can I please get your full name and age please? * Mr. Doe, today my attending physician has asked me to examine your Cranial Nerves, do I have your permission? 2. Explains procedure to patient, positions and drapes. * For today's examination we'll be checking your sense of '''smell''' and '''vision''', are you comfortable with that? * I just want to remind you that anything we discover will be '''confidential'''. * Are you '''comfortable'''? Is there anything you need before we begin? 3a. Inspect the nasal cavities looking for blockage, discharge, etc. Inspect the eyes looking for anisocoria, conjunctivitis, subconjunctival hemorrhage. * I'm going to inspect the nasal cavities with my '''penlight'''. ** I don't see any signs of '''blockage''' or '''discharge'''. * I'm now going to inspect your '''eyes'''. ** I don't see any signs of [[Anisocoria]] in the eyes which is unequal pupil size. ** I do not see any signs of '''narrow angle glaucoma'''. ** I do not see any signs of '''conjunctivitis'''. ** I do not see any signs of '''subconjunctival hemorrhag'''e which are bright red spots in the conjunctival. ** I do not see any signs of '''strabismus''' which is misalignment of the eyes. 3b. CN1: Examine and comment on findings. * Mr. Doe, can you please close one of your nostril and both your eyes. * Can you tell me what you smell please? * Now please close your other nostril; please tell me what you smell. * Thank you Mr. Doe, you can now open your eyes. * The patient was able to smell the scent which means Cranial Nerve I is intact. * Loss of smell can indicate and: ** Sinus conditions ** Head trauma ** Smoking ** Aging ** Cocaine ** PD (Parkinson's Disease) 4. CN 2: Check Visual Acuity on Snellen chart and comment on finding. * Mr. Doe, I'm going to check your vision now. * Do you use reading glasses or contacts? ** If yes: Please put them on. * '''Far Vision''' ** *Stand 20 feet away with a Snellen eye chart* ** Please cover one eye and read the smallest line. *** Record the visual acuity findings. ** The patient's visual acuity is 20/30 which means that at 20 feet, the patient can read print that a person with normal vision can read at 30 feet. ** 20/20 is normal far vision. ** 20/ >20 is [[myopia]]. * '''Near Vision''' ** *Hold a piece of paper containing print 14" from the patient and ask them to read it.* ** The patient was able to read the print, which means the patient does not have '''presbyopia''' or impaired near vision. 6. Check visual fields by confrontation and comment on finding. * Okay Mr. Doe, I'm going to check for you visual fields now, please look at my eyes. * I'm going to be moving my fingers towards you, please let me know when you see them. * *Repeat for upper and lower quadrants* * *Findings* * The patient was able to see both sets of fingers at the same time which means his visual fields is normal. * Some types of visual field defects are: ** '''Horizontal''' '''defect''' caused by '''glaucoma'''. ** '''Unilateral blindness''' caused by '''optic neuritis''' ** '''Bitemporal blindness''' caused by '''pituitary tumor'''. ** '''Homonymous hemianopia''' or '''quadrantanopia''' caused by '''stroke'''. 7. Tests direct and consensual pupillary reflexes and comment on finding. Describe findings in Horner's Syndrome, Argyll Robertson Pupils & Afferent Pupillary Defect (Marcus Gunn Pupil) * Mr. Doe, I'm now going to check your pupillary reflex, please look straight ahead of you into the distance. * *Shine light into the pupil* * I was able to see constriction in the left eye. * I was able to see constriction and consensual reaction of the pupils which is a normal pupillary reflex. * If the pupil constricts to light but does not dilate in absence of light, this can suggest Horner's Syndrome. ** Other symptoms of '''Horner's Syndrome''' include: *** Ptosis *** Miosis *** Anhydrosis * Argyll Robertson Pupils ** Neurosyphilis * Marcus Gunn Pupil ** Lesion of the Optic Nerve. 8. Check for accommodation and comment on findings. * Mr. Doe, please follow my fingers with your eyes. * I was able to see '''pupillary''' '''constriction''' when going from '''distant''' to '''near''', this is a '''normal''' accommodation reflex. * '''Normal''' accommodation with '''abnormal''' light reflex can suggest '''Argyll''' '''Robertson''' which is associated with '''syphilis'''. * '''Delayed''' or '''absent''' pupillary reflex with '''delayed''' accommodation is associated with '''tonic''' '''Adie's''' '''pupil'''. * '''Fixed''' dilated pupil with '''no''' light reflex and '''no''' accommodation is associated with '''Cranial''' '''Nerve''' '''III''' '''paralysis'''. * That's all for your exam today, thank you for coming in. 9. Knowledge Question